An Introduction to IMPACT Sunnybrook Health Sciences Centre GiiC Knowledge-to-Practice Workshop Presenters: Susan Riddle & Jasmine Arellano

What it is Interprofessional Model of Practice for Aging and Complex Treatment A comprehensive model of: Assessment Care Mentorship and training Planning

What it is An interdisciplinary team works with patient, caregiver(s), and referring practitioner Typical appointment covers a diverse range of medical, functional and psycho-social issues Goal: ‘unpack’ the patient’s condition Takes 2-3 hours Complements family practitioners’ care

What it is Room to personalize process according to context Builds on unique characteristics of the patient being assessed Builds on unique characteristics of the team in place What is unique about our IPC approach? All team members are present, TOGETHER, in a room observing all patient encounters over live video feed which creates instantaneous information sharing Patient visits last 1.5-2 hours long, and on average the team sees 2 patients/clinic Project Activities Weekly Friday morning clinic since February 2008 Whole Team observing

IMPACT HCPs The team comprises: Family physician Family physician resident Pharmacist Occupational therapist Physiotherapist Community nurse Social worker Dietician 5

Patient on Screen Doctor Resident 1 Resident 2 HCP learner Physio OT Researchers OT Dietician Pharmacist Community Nurse Social Worker 6

The IMPACT patient Inclusion criteria aged 65+ 5 or more long term medications 3 or more chronic disease requiring monitoring and treatment OR 2 chronic diseases when one is frequently unstable minimum of 1 functional ADL limitation not home-bound or institutionalized patient and/or caregiver is willing and able to deliberate with a team patient and/or caregiver are motivated to take action to improve patient’s health status and patient is emotionally/cognitively/socially equipped to do so The inclusion criteria we’ve come up with for IMPACT aren’t set in stone. Please keep in mind that they’re not absolute requirements – they’re recommendations 8

The IMPACT protocol 9 Patient Selection & Invitation Group Discussion 1 Patient Welcome & Initial Patient Interview Group Discussion 2 HCP Assessments Team Deliberation Documentation & Debrief 9

Patient Selection & Invitation Selection based on inclusion criteria Invitation extended to patient/caregiver Patient Selection & Invitation Group Discussion 1 Patient Welcome & Initial Patient Interview Group Discussion 2 HCP Assessments Team Deliberation Documentation & Debrief

Group Discussion 1 Referring practitioner provides background info: Brief history Recent events Current issues/concerns Patient’s support systems Rationale for bringing patient to IMPACT Patient Selection & Invitation Group Discussion 1 Patient Welcome & Initial Patient Interview Group Discussion 2 HCP Assessments Team Deliberation Documentation & Debrief

Patient Welcome & Initial Patient Interview Patient and caregiver greeted Patient and caregiver interviewed, team observes and gathers data on: Current concerns, current function; patient and family goals and perspectives Interviewer summarizes patient and family concerns Patient Selection & Invitation Group Discussion 1 Patient Welcome & Initial Patient Interview Group Discussion 2 HCP Assessments Team Deliberation Documentation & Debrief

Group Discussion 2 Interviewer debriefs team and priorities for visit are identified Issues and concerns Which HCPs will see patient and caregiver Additional information needed? Patient Selection & Invitation Group Discussion 1 Patient Welcome & Initial Patient Interview Group Discussion 2 HCP Assessments Team Deliberation Documentation & Debrief Would team benefit by speaking to patient and caregiver separately?

HCP assessments Relevant HCPs perform assessments of patient, caregiver Social worker Occupational therapist Physical therapist Nurse Dietitian Pharmacist Patient Selection & Invitation Group Discussion 1 Patient Welcome & Initial Patient Interview Group Discussion 2 HCP Assessments Team Deliberation Documentation & Debrief

Team Deliberation HCPs discuss situation in light of findings of team members’ assessments Investigation/treatment options discussed Care plan begins to take shape What does the patient/caregiver want? What can the patient achieve? Patient Selection & Invitation Group Discussion 1 Patient Welcome & Initial Patient Interview Group Discussion 2 HCP Assessments Team Deliberation Documentation & Debrief We want to make sure that care plan involves the patient and caregiver – this is patient centred care. We make recommendations based on the issues diagnosed by HCP or identified by patient.

Documentation and Debrief Dialogue with patient/ caregiver to ensure their needs and expectations have been met Patient plan of care negotiated with input from patient and caregiver/family Resources and patient to-do list provided Patient medical records completed Patient Selection & Invitation Group Discussion 1 Patient Welcome & Initial Patient Interview Group Discussion 2 HCP Assessments Team Deliberation Documentation & Debrief The intention is that care plan is developed based on the team’s recommendations and the patients’ wants/needs. Recommendations are discussed with patient / caregiver and implemented if complete agreement is reached.

Patient Follow-up Follow-up visit with FP and care plan review Community visits from IMPACT team members Ongoing team communication 17

Highlights of the IMPACT experience Very different from patients’ typical encounters with their family physician Group discussion, shared observation Final recommendations arrived at through a collaborative and interprofessional process Effectiveness Real-time problem solving Addressing patient and caregiver priorities Avoids multiple referrals -less disease focused -holistic -balance -equilibrium 18

Highlights of the IMPACT experience Shared knowledge and perspectives Sharing of expertise, knowledge Different professional and personal approaches Opportunity to draw on expertise of entire team “Interprofessional collaborative knowledge construction” Observation Can see interactions Referring FP sees patient in a “new light” Practitioners discuss their impressions as a group, and observe or participate in each others’ examinations or assessments. Knowledge is shared amongst the team one practitioner may incorporate information obtained by a practitioner of another discipline in his or her assessment The team’s final recommendations to the patient, family and referring practitioner are arrived at through a collaborative and consultative process. 19

IMPACT Successes Appeal to patients and caregivers Patients feel better able to express themselves with longer appointments “...so within the first 10-15 minutes, mom has a comfort level that she never had before and is more forthcoming than ever.” –Family member Patients feel that they are being listened to “IMPACT is a huge improvement. They’re hearing the patient, finally they are, they have the time.” –Family member

Appeal to patients and caregivers Patients felt important and supported by the care team “ Well, it was just wonderful. I felt taken care of… I felt um, I hate to say this, special” –Patient

Thank you! Questions?

"Frail older patients – unlike younger persons in the health care system or even well elders – require complex care. Most frail older patients have multiple chronic illnesses. Optimum care cannot be achieved by following the paradigm of ongoing traditional health care, which emphasizes disease and cure. Because no one health care professional can possibly have all of the specialized skills required to implement such a model of health care delivery, interdisciplinary team care has evolved.” Dyer et al. Frail Older Patient Care by Interdisciplinary Teams. Gerontology & Geriatrics Education 2004;24(2): 51-62. 23